- Critics of psychiatry claim there is an “epidemic” of mental illness in the US—and some argue this is a consequence of psychiatric treatment. But the best epidemiologic evidence reveals no such epidemic in this country, rendering the iatrogenic “explanation” null and void
- If antidepressant treatment were truly “driving” an epidemic of major depression—or substantially worsening existing cases—we would expect to see this reflected in rising incidence and prevalence figures. But neither has been detected for the US population as a whole
- Rates of treatment (psychotherapy or medication) for a given disorder may be misleading with respect to actual prevalence of an illness
Similarly, rising rates of medication prescription—although of potential concern from the clinical and societal standpoint—cannot serve as a reliable proxy for actual incidence or prevalence rates. Prescribing patterns may be subject to fluctuations owing, for example, to rates of direct-to-consumer advertising or to public and professional awareness of a particular condition. Neither can office-based rates of psychiatric diagnoses serve as reliable indices of illness incidence or prevalence, since clinicians differ widely in their application of DSM diagnostic criteria, which are often ignored.18 So, for example, office-based data showing markedly rising rates of bipolar disorder diagnosis in younger patients19—certainly a matter of parental and medical concern—do not necessarily indicate an increase in actual cases of bipolar disorder in the younger population. For one thing, it is not clear how strictly formal criteria for bipolar disorder were applied by clinicians—so over-diagnosis could have occurred. Indeed, as NIMH Director, Thomas R. Insel, MD, observed, “We do not know how much of this increase reflects earlier under-diagnosis, current over-diagnosis, possibly a true increase in prevalence of [bipolar disorder], or some combination of these factors.”20 Even rates of treatment (psychotherapy or medication) for a given disorder may be misleading with respect to actual prevalence of an illness, since psychiatric treatment availability is subject to socioeconomic variables, such as insurance coverage, proximity to mental health practitioners, and ethnic minority status.21
In sum: although important for other reasons, none of these measures—disability rates, prescribing patterns, or rates of treatment—is a valid means of determining an illness’s incidence or prevalence. None is a “proxy,” or substitute, for applying consistent diagnostic criteria and/or using structured clinical interviews in comparable populations, over long periods of time.
Serious mental illness in younger populations
Thus far, we have reviewed data primarily derived from adult populations. But what about children and adolescents, in whom an “epidemic” of mental illness has been alleged?22† Recently, Olfson et al23 looked at rates of mental health impairment among young people who receive mental health care in the United States, focusing on the severity of mental health impairment. Data were derived from the household component of the 1996-2012 Medical Expenditure Panel Surveys conducted by the Agency for Healthcare Research and Quality, and the sample study (N = 53,62) included all persons 6 to 17 years of age. Mental health functioning was assessed with the use of the parent version of the Columbia Impairment Scale (CIS)—a 13-item measure of child and adolescent interpersonal relations, psychopathological symptoms, functioning in school, and use of leisure time. To the surprise of the authors, the percentage of young people with more severe mental health impairment (CIS score ≥16) declined from 12.8% in 1996-1998, to 11.9% in 2003-2005, to 10.7% in 2010-2012. Significant declines in the odds of more severe mental health impairment were observed among children, adolescents, male youths, female youths, and Hispanics.
Other data in younger psychiatric populations also undermine the “epidemic” narrative. For example, Costello and colleagues24 reviewed epidemiological studies of children born between 1965 and 1996. Meta-analysis was performed on all studies that used structured diagnostic interviews to make formal diagnoses of depression on representative population samples of participants. Twenty-six studies were identified, generating nearly 60,000 observations on children who had received at least one structured psychiatric interview. The authors concluded that,
When concurrent assessment rather than retrospective recall is used, there is no evidence for an increased prevalence of child or adolescent depression over the past 30 years. Public perception of an “epidemic” may arise from heightened awareness of a disorder that was long under-diagnosed by clinicians.24
Similarly, results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A),25 which examined lifetime prevalence data of mental disorders in a nationally representative sample of US adolescents, found no evidence of substantially increased rates of major depression, compared with earlier NCS data. And, with respect to bipolar (BP) disorder, a recent review26 concluded that “. . . there was no evidence of increasing prevalence of BP spectrum disorders over time . . .” as ascertained by rigorous semi-structured interviews. This is in contrast to increased frequency of office-based BP diagnosis. While this disparity may indicate shortcomings in clinical assessment—eg, “. . . insufficiently stringent application of diagnostic criteria in clinical settings . . .”26—it does not point to an “epidemic” of actual bipolar disorder in younger populations. Furthermore, these same authors found that “. . . low rates of treatment of youth with BP suggest that withholding of BP diagnoses may also be common.”
The present review provides little support for the view that serious psychiatric disorders are on the rise, or that there is a “raging epidemic”1 of SMI in the US—either in adult or younger populations. On the contrary, rates of SMI appear to be either declining or fairly stable in this country. Relatively stable rates also apply with respect to the incidence and prevalence of, for example, major depression and schizophrenia. The incidence and prevalence of mental illness cannot be reliably inferred from changes in medication prescription rates, office-based diagnosis or treatment rates, or rates of putative “disability” attributed to mental illness. Only the uniform application of defined clinical criteria over long periods—or structured, clinical interviews—can yield reliable information on incidence and prevalence. There is no credible epidemiological evidence that psychotropic medication per se has led to rising rates of SMI, or increased rates of any specific psychiatric disorders in the general population.
Absent a demonstrable “epidemic” of mental illness in the US, the entirely speculative hypothesis that there is “a biological cause for the epidemic”2 is rendered nonsensical. Notwithstanding these conclusions, we need better prospective methods of tracking incidence and prevalence of psychiatric illness in this country. Ideally, assessments should be made contemporaneously with the index episode of illness, rather than inferred retrospectively. We also need to ensure that clinicians apply standard criteria for diagnosing psychiatric disorders—particularly in younger populations—and prescribe medication with care and vigilance. Equally urgent, we need to ensure that those with serious psychiatric illness have access to care and treatment by psychiatrists and other mental health professionals.21
* Rates of bipolar disorder vary considerably from country to country, and some evidence points to higher lifetime prevalence rates in the US than in several other countries. This “...may reflect methodologic differences in diagnostic procedures or assessment methods as well as true differences in disease prevalence.” (Merikangas KR, Jin R, He JP, et al. Arch Gen Psychiatry. 2011;68:241-251.)
† I have not dealt with ADHD in children because the criteria for this condition have changed significantly over the past 40 years, and estimates of prevalence depend crucially on how DSM criteria are applied by clinicians. The CDC reports that surveys asking parents whether their child received an ADHD diagnosis from a health care professional show that the percentage of children with an ADHD diagnosis increased from 7.8% in 2003 to 9.5% in 2007 and to 11.0% in 2011. But even assuming that the diagnoses provided by clinicians were valid, a roughly 3% increase spread over 8 years would not qualify as an “epidemic.” Commenting on these trends, the CDC notes: “It is not possible to tell whether this increase represents a change in the number of children who have ADHD, or a change in the number of children who were diagnosed. Perhaps relatedly, the number of FDA-approved ADHD medications increased noticeably since the 1990s, after the introduction of long-acting formulations.” (ADHD throughout the years. October 6, 2014. http://www.cdc.gov/ncbddd/adhd/timeline.html.)
Acknowledgment: I wish to thank Dr Kathleen R. Merikangas for providing important background reference material. The views represented here, however, are my own.
Note to readers: As with all of our blogs, the opinions expressed in this commentary are solely those of the author. Comments not followed by full names and academic titles will either be removed or heavily monitored. –Psychiatric Times
Dr Pies is Editor in Chief Emeritus of Psychiatric Times, and a Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. He is the author of The Judaic Foundations of Cognitive Behavioral Therapy; The Three-Petalled Rose; and Psychiatry on the Edge (collected essays from Psychiatric Times/Nova Publishing).
1. Cf. Dr. Marcia Angell: “It seems that Americans are in the midst of a raging epidemic of mental illness, at least as judged by the increase in the numbers treated for it.” Angell M. The Epidemic of Mental Illness: Why? The New York Review of Books. June 23, 2011.
2. Whitaker R. Anatomy of an epidemic: psychiatric drugs and the astonishing rise of mental illness in America. Ethical Hum Psychol Psychiatry. 2005;7:23-35. http://freedom-center.org/pdf/anatomy_of_epidemic_whitaker_psych_drugs.pdf. Accessed June 18, 2015.
3. Pies R. Does psychiatry medicalize normality? Philosophy Now. November/December 2013. https://philosophynow.org/issues/99/Does_Psychiatry_Medicalize_Normality
4. UCLA Fielding School of Public Health. Definitions. http://www.ph.ucla.edu/epi/bioter/anthapha_def_a.html. Accessed June 18, 2015.
5. Pies RW. Is there really an “epidemic” of psychiatric illness in the US? Psychiatr Times. May 1, 2012. http://www.psychiatrictimes.com/articles/there-really-%E2%80%9Cepidemic%E2%80%9D-psychiatric-illness-us. Accessed June 18, 2015.
6. Insel T. National Institute of Mental Health. Director’s blog: getting serious about mental illnesses. July 31, 2013. http://www.nimh.nih.gov/about/director/2013/getting-serious-about-mental-illnesses.shtml. Accessed June 18, 2015.
7. Epstein J, Barker P, Vorburger M, Murtha C. Serious Mental Illness and Its Co-Occurrence With Substance Use Disorders, 2002. http://www.ce-credit.com/articles/100995/CoD.pdf. Accessed June 18, 2015.
8. National Institute of Mental Health. Serious mental illness (SMI) among US adults. http://www.nimh.nih.gov/health/statistics/prevalence/serious-mental-illness-smi-among-us-adults.shtml. Accessed June 18, 2015.
9. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The NSDUH Report: Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings. http://www.samhsa.gov/data/sites/default/files/NSDUH-SR200-RecoveryMonth-2014/NSDUH-SR200-RecoveryMonth-2014.htm. Accessed June 18, 2015.
10. Substance Abuse and Mental Health Services Administration. Results From the 2010 National Survey on Drug Use and Health: Mental Health Findings. http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2010/NSDUHmhfr2010.htm#1.4. Accessed June 18, 2015.
11. Kessler RC, Berglund PA, Zhao S, et al. The 12-month prevalence and correlates of serious mental illness (SMI). In: Manderscheid RW, Sonnenschein MA, eds. Mental Health, United States, 1996. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. DHHS publication SMA 96-3098.
12. Häfner H, an der Heiden W. Epidemiology of schizophrenia. Can J Psychiatry. 1997;42:139-151.
13. Kirkbride JB, Errazuriz A, Croudace TJ, et al. Incidence of schizophrenia and other psychoses in England, 1950-2009: a systematic review and meta-analyses. PLoS One. 2012;7:e31660. Epub 2012 Mar 22.
14. Eaton WW, Kalaydjian A, Scharfstein DO, et al. Prevalence and incidence of depressive disorder: the Baltimore ECA follow-up, 1981-2004. Acta Psychiatr Scand. 2007;116:182-188.
15. Pratt LA, Brody DJ, Gu Q. Antidepressant use in persons aged 12 and over: United States, 2005-2008. NCHS data brief, no 76. Hyattsville, MD: National Center for Health Statistics; 2011.
16. Substance Abuse and Mental Health Services Administration. Results From the 2013 National Survey on Drug Use and Health: Mental Health Findings. http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.htm#2-3. Accessed June 18, 2015.
17. Ultimate Social Security Disability Guide: SSDI, SSI, How to Win, Information: Social Security Disability Hearing and How to Prepare for Disability Hearing. http://www.ultimatedisabilityguide.com/disability_hearing.html. Accessed June 18, 2015.
18. Zimmerman M, Galione J. Psychiatrists’ and nonpsychiatrist physicians’ reported use of the DSM-IV criteria for major depressive disorder. J Clin Psychiatry. 2010;71:235-238.
19. Moreno C, Laje G, Blanco C, et al. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007;64:1032-1039.
20. National Institutes of Health. Rates of bipolar diagnosis in youth rapidly climbing, treatment patterns similar to adults. 2007. http://www.nih.gov/news/pr/sep2007/nimh-03.htm. Accessed June 18, 2015.
21. González HM, Vega WA, Williams DR, et al. Depression care in the United States: too little for too few. Arch Gen Psychiatry. 2010;67:37-46.
22. DeAngelis T. Children’s mental health problems seen as “epidemic.” American Psychological Association. 2004. http://www.apa.org/monitor/dec04/epidemic.aspx. Accessed June 18, 2015.
23. Olfson M, Druss BG, Marcus SC. Trends in mental health care among children and adolescents. N Engl J Med. 2015;372:2029-2038.
24. Costello EJ, Erkanli A, Angold A. Is there an epidemic of child or adolescent depression? J Child Psychol Psychiatry. 2006;47:1263-1271.
25. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49:980–989.
26. Goldstein BI, Birmaher B. Prevalence, clinical presentation and differential diagnosis of pediatric bipolar disorder. Isr J Psychiatry Relat Sci. 2012;49:3-14.